Patricia L. Hale, MD, PhD, FACPDeputy DirectorOffice of Health Information Technology TransformationNew York State Department of Health www.pathalemd.com

E-Prescribing Overview: What Works; What Doesn't and How Do We Implement It?

E-Prescribing Overview: What Works; What Doesn't and How Do We Implement It?

HIMSS 09 Physicians' IT Symposium: Closing the Gap: From Implementation to Safety & QualitySaturday, April 4, 3:00 PM - 4:00 PM

HIMSS 09 Physicians' IT Symposium: Closing the Gap: From Implementation to Safety & QualitySaturday, April 4, 3:00 PM - 4:00 PM

Objectives:

Review the positive and negative points of e-Prescribing

Discuss implementation of e-Prescribing

Examine the challenges of implementation

Source: The Institute of Medicine of the National Academies of Science (IOM). Slide used by permission from SureScripts

More than7,000 Americans Die Annually From Preventable Medication Errors

More than 1.5 Million Americans are Injured Annually by Preventable Medication Errors

Physicians write as many as

4 billion prescriptions

each year. . . .

On Paper!

The Challenge of “Prescription Hand-offs”

• Illegible Handwriting

• Unclear Abbreviations and Doses

• Verbal Communication Among Physicians, Patients and Pharmacists

4 out of 5 patients who visit a physician leave with at least one prescription

65% of the US population use a prescription medication each year

Less than 1 in 5 of Physicians Use ePrescribing

Only 20% of prescriptions are electronically prescribed with 80% still handwritten

Most electronic prescriptions are still sent by FAX

Sources: eHealth Initiative, 2004 and: Center for Information Technology Leadership, “The Value of Computerized Provider Order Entry in Ambulatory Settings,” 2003.

National savings from universal adoption ofelectronic prescribing systems could be more than $27 billion

Patient safety Between 1.5%-4.0% prescriptions

are in error with serious patient risk

Adverse drug events occur in 5%-18% of ambulatory patients

Cost of errors: >$2 billion / year

Quality of care - Compliance 20% of scripts are never filled Patient satisfaction is declining

Impact on productivity: Physician practice: 3 hours per day Pharmacy: 4 hours per day (up to 1

call per Rx) Inefficient delivery with paper, fax

and phone

• Illegible handwriting

• Phone tag and fax tag

• Patient waiting in the pharmacy

• Illegible handwriting

• Phone tag and fax tag

• Patient waiting in the pharmacy

Rx

Rx

PenPrint6%

Fax37%

EDI+

Decision Support

61%

Source: CITL Slide used by permission from SureScripts

Ability to create a prescription electronically Ability to receive automated decision support during script

creation Medication lists and information Eligibility determination Formulary coverage from insurer including co-pay information Prior authorization clinical decision support including Drug interactions, drug-

allergy, etc. Ability to send script electronically to pharmacy using standard

transmission messaging (NCPDP SCRIPT, ASC12) Ability to receive/authorize pharmacy initiated-renewals

electronically Ability to determine “fill status” as a measure of compliance

(medication history) Ability for pharmacy to process electronic script in their system

Slide used by permission from SureScripts

Prescriber

eRx Software

Pharmacy and PBM

eRx Software

New Rx, refills, renewals,

authorizations, change Rx, Prescription history from pharmacies

Eligibility, Formularies, medication

claims histories

Certified version typically a simple upgrade away

Extremely low awareness among install base

RxInterOp

>150,000 Certified EMR Users

Practice Size

Best estimates for ePrescibing or EMR adoption based on

high quality surveys (%)

All 24

Small 7-16

Large* 39*”Large” is defined as > 20 physician FTEs in one study with 39% adoption and >50 in two another studies with 47% and 57% adoption respectively.

Sources: Jha et al, Health Affairs, 10/11/06; MGMA, 2005; CDC/NCHS Nat’l Ambulatory Medical Care Survey, 2005; HSC Community Tracking Study, 2006; Forrester, 2003; SureScripts estimates, 2006

Less than 1 in 5 of Physicians Use ePrescribing Only 20% of prescriptions are electronically

prescribed with 80% still handwritten Most “electronic” prescriptions are still sent

by FAX National savings from universal adoption of e-

prescribing systems could be more than $27 billion

We remain at the tipping point of adoption of clinical systems at the point of care

Early adopters are now on board and EMRs are becoming mainstream in large practices

MainstreamMarket where

incentives are most effective

EnthusiastsAnd Early

Adoptees

2.5% 13.5% 34% 34% 16%

TippingPoint??

Mandates to reach non-adopters

Mandates to reach non-adopters

eHIT

>80% Payors/PBMs:

Increased generic/formulary usage, efficiency, Rx compliance and prevention of ADEs (reduced costs)

Patients: Increased safety, efficiency and compliance Lower co-pays

>20% Providers:

Increased efficiency, improved care, patient satisfaction and potential short and long term incentives (pay-for-performance)

Pharmacies: Increased efficiency, improved care, improved patient

satisfaction

Discovery of potentially significant drug-drug, drug-allergy or drug-lab interactions;

Reduced adverse drug events (ADE), Reduced avoidable emergency department visits or hospital

admissions; Eliminated transcription or legibility errors; Availability of a more complete, up-to-date medication list

for each patient; Increased practice efficiency (particularly med renewal

requests); Increased prescriber efficiency (e.g., fewer call-backs from

pharmacies); More effective medication reconciliation across multiple

settings of care; Increased patient satisfaction.MGMA 2008 survey:MGMA 2008 survey:

© RxHub LLC, 2008Proprietary and Confidential

16

Cost of buying, installing and supporting a systemand Return on Investment (ROI)

Financial Cost Change Management and Workflow

Lack of reimbursement for costs and resources Increased time to use the system = reduced

productivity (initially) while struggling to create efficient workflows

Challenges of creating a complete, accurate patient medication history from multiple sources

Time required to review medications, warnings, alerts and recommendations

Limitations preventing use for all prescriptions due DEA restriction from use for controlled medications and other Federal and State rules and regulations

Hardware and Software Selection and support Limitations on E-Prescribing System Remote

Access Pharmacy, Payer/PBM and Mail Order

Connectivity Medication History and Medication Reconciliation System Functionality Gaps Prescribing from Multiple Office Sites or remotely

…..Still not considered a routine standard of practice

Business case varies according to: ▪ Size of practice ▪ Type of practice (primary care vs specialty,

mostly new patients, mostly recurrent complex patients, etc)

▪ Participation of health plans▪ Participation of local pharmacies▪ Practice setting (large/small, urban/rural) ▪ Availability of IT infrastructure and support▪ Stand alone e-prescribing vs EHR ▪ Availability of incentives and ability to take

advantage of them

Initial costs include software licensing fees, hardware, network and Internet access and training and technical support

Complete cost will also include Temporary decreases in productivity resulting from

training and workflow redesign (averaging 2-6months)

Practice management, lab and other interfaces Customization for practice specialty and other

factors Maintenance of system Upgrades Data conversation (from different PMS or from stand

alone e-prescribing system to EHR)

Stand alone e-Prescribing start up and ongoing cost estimated at $1000 - $3500 per physician per year for software plus hardware etc

EMR costs estimated at $20-25,000 initial and $3000 per year per physician for software plus hardware etc

Costs are less in urban areas where Internet and IT services are more readily available

Large practices can save significantly through cost sharing and increased efficiency of implementation and support by being able to afford dedicated staff

Both stand alone e-prescribing systems and EHRs

Increased practice efficiency handling med renewal requests

Increased prescriber accuracy resulting in fewer call-backs from pharmacies for legibility issues, drug incompatibility or ineligibility

EHRs Decreased chart pulls resulting in less staff

time Decreased transcription costs

Advantages:▪ Financial investment capability▪ Dedicated staff opportunity▪ Leverage with health plans and pharmacies, etc for connectivity▪ Often can leverage other incentive opportunities with health plans, P4P, PQRI etc.

Disadvantages: ▪ Organizational “buy in” with large potentially diverse physician staff often resulting in “hold outs” and partial implementations▪ Major changes in workflow can be disruptive decreasing productivity making clinician payment strategies etc in need of temporary modifications▪ Significant Initial cost

Advantages:▪ Organizational “buy in” less of an issue▪ Less total initial investment

Disadvantages▪ Difficult to absorb cost including system cost and decreased productivity▪ Can have connectivity issues and difficulty obtaining skilled IT support ▪ No leverage with health plans or pharmacies resulting in decreased opportunity for optimum data flow▪ No opportunity for dedicated staff to maximize success or take advantage of other incentives like P4P and PQRI

Practice Setting

Practice type

Prescriptions and Refills/day/ prescriber

Stand Alonee-Prescribing* length

of time to achieve +ROI***

EMR** approximate length of time to achieve +ROI****

RuralSmall 1-5 Docs

Primary Care

40/60 3-5+years 3-5+years

“ Specialty 20/40 2-5+ years 2-5+ years

Rural Large 10+

Primary Care 40/60 2-3+ years 2-4+ years

“ Specialty 20/40 1-3+ years 2-4+ years

Urban Small 1-5

Primary care 40/60 2-3+ years 2-4+ years

“ Specialty 20/40 1-3+ years 2-4+ years

Urban Large 10+

Primary Care 40/60 1-2+ years 2-3+ years

“ Multispecialty

20/40 0.5-2+ years 1-3+ years

*Stand alone e-Prescribing start up and ongoing cost estimated at $1000 - $3500 per physician per year for software plus hardware etc**EMR initial and ongoing yearly costs estimated at $20-25,000 initial and $3000 per year per physician for software plus hardware etc*** Stand alone e-Prescribing ROI calculated using savings estimates for time savings due to automated refill requests and decreased phone calls resulting in decreased staff time**** EHR ROI calculated using savings estimates from e-Prescribing plus decrease chart pulls (staff time) and decreased transcription costsReferences: MGMA survey 2007, 2008; Medical Group Management Association, “The cost of administrative complexity,” MGMA Connexion,November/December 2004; “Evidence on the Costs and Benefits of Health Information Technology”. May 2008. Congressional Budget Office

*Stand alone e-Prescribing start up and ongoing cost estimated at $1000 - $3500 per physician per year for software plus hardware etc**EMR initial and ongoing yearly costs estimated at $20-25,000 initial and $3000 per year per physician for software plus hardware etc*** Stand alone e-Prescribing ROI calculated using savings estimates for time savings due to automated refill requests and decreased phone calls resulting in decreased staff time**** EHR ROI calculated using savings estimates from e-Prescribing plus decrease chart pulls (staff time) and decreased transcription costsReferences: MGMA survey 2007, 2008; Medical Group Management Association, “The cost of administrative complexity,” MGMA Connexion,November/December 2004; “Evidence on the Costs and Benefits of Health Information Technology”. May 2008. Congressional Budget Office

Where do they fit in?

Economic Incentives Reimbursement for Utilization Incentive programs

disincentive programs▪ MIPPA▪ ARRA▪ Other programs sponsored by Medicaid, private health plans, employers and

others Grants, Loans and other funding programs Pay for Performance Malpractice Insurance Premium Reductions Healthcare IT Suppliers discounts, group buying programs, etc

Policy Incentives and Programs for Implementation Support Accreditation (JCAHO 2005 Hospitals’ National Patient Safety Goals, others in

development) Relaxed STARK regulations CMS DOQ-IT CCHIT certification of “free standing” E-prescribing and

ambulatory EHR products …and eventually…Mandates??

Beginning January 1, 2009, Medicare offers physician payment incentives of 2% for using e-prescribing in 2009 and 2010, with this amount declining slightly over the following three years.

Those physicians who do not adopt e-prescribing for Medicare by 2012 will start seeing their Medicare payments incrementally reduced, up to 2% annually beginning in 2014. The Secretary of Health and Human Services may make an

exemption on a case-by case basis if significant hardship can be demonstrated.

Health plans offering Medicare Part D drug programs must begin supporting e-prescribing by May, 2009.

The Secretary has the authority to update the codes of the electronic prescribing measure in the future. The legislation refers specifically to the electronic prescribing measure currently in the 2008 Physician Quality Reporting Initiative (PQRI) (measure #125)

CCHIT certification is required for both “free standing” e-prescribing and EHR products

The stimulus package includes $36B in health IT funding from the federal government through Appropriations and Incentives

E-Prescribing and ARRA

Appropriations for Health IT & HIE

New Incentives for Adoption

$2 billion for loans, grants & technical assistance:

• HIE Planning & Implementation Grants

• EHR State Loan Fund

• National Health IT Research Center & Regional Extension Centers

• Workforce Training

• New Technology R&D

New Medicare and Medicaid payment incentives to providers for EHR adoption

• $20 billion in expected payments through Medicare

• $14 billion in expected payments through Medicaid

• ~$34 billion in gross expected outlays, 2011-2016

$4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grants

•Directs ONC to invest in telehealth infrastructure and tools

•Directs the new FACA Policy Committee to consider telehealth recommendations

Broadband and Telehealth

Comparative Effectiveness

$1.1 billion to HHS for CER

• Establishes Federal Coordinating Council to assist offices and agencies of the federal government to coordinate the conduct or support of CER and related health services

HHS to establish interoperability

standards by the end of 2009

to guide HIE development

MIPPA and ARRA Timeline

2009

Setting of standards enables the building of HIE infrastructure

to practically and usefully implement standards to achieve interoperability to comply with

Medicare and Medicaid incentive payment requirements for HIE

interoperability

State grant monies begin flowing from HHS to develop technical, privacy, governance and financing frameworks necessary for HIE to take shape...likely

09/10

2011

Medicare and Medicaid ARRA

incentive payments begin, presuming HIEs

have come online

2016

Medicare and Medicaid ARRA

incentive payments give way to penalties

on providers for failing to adopt HIT

2010 2012 2013 2014 2015

MIPPA e-

prescribing

incentives

begins

MIPPA e-Prescribing incentive payments give

away to penalties

Three Components Uses EHR in a meaningful manner, which

includes electronic prescribing as determined to be appropriate by the HHS Secretary

Uses EHR that is “connected in a manner” that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination (in accordance with law and standards applicable to the exchange of information)

Submits information on clinical quality measures and other measures as selected and in a form and manner specified by the Secretary

2011 is first year

2012 is first year

2013 is first year

2014 is first year

2015 is first year

2011 $18,000

2012 $12,000 $18,000

2013 $8,000 $12,000 $15,000

2014 $4,000 $8,000 $12,000 $15,000

2015 $2,000 $4,000 $8,000 $12,000 0

2016 $0 $2,000 $4,000 $8,000 0

TOTAL

$44,000 $44,000 $42,000 $35,000 0

Medicare Health IT Physician Payment Incentives

Eligible Provider Percent Match/ Limit

Medicaid Share Limit Amount

Independent physician

85% net average allowable costs

>30% $25,000 for purchase$10,000 for

operations/maintenanceMax of $64,000 in 5 years

Pediatrician 85% net average allowable costs

>20% $16,667 for purchase, $6,667 for operations/maintenanceMax of $51,200 in 5 years

Nurse mid-wife 85% net average allowable costs

>30% $25,000 for purchase$10,000 for

operations/maintenanceMax of $64,000 in 5 years

Physician Assistant if is lead clinician at RQHC or FQHC

85% net average allowable costs

>30% of patient population are “needy individuals”

By determination of the Secretary

Nurse practitioner 85% net average allowable costs

>30% $25,000 for purchase$10,000 for

operations/maintenance Max of $64,000 in 5 years

Hospital owned clinician practice

85% net average allowable costs

>10% $25,000 for purchase$10,000 for operations/maintenance Max of $64,000 in 5 years

FQHC or RQHC-based practicing physician

85% net average allowable costs

>30% of patient population are “needy individuals”

$25,000 for purchase$10,000 for

operations/maintenance Max of $64,000 in 5 years

Third-party sponsoring entity supporting EHR implementation

85% of net allowable costs; third-party entity can keep 5% of funds as pass-through

>30% $25,000 for purchase$10,000 for

operations/maintenance Max of $64,000 in 5 years

Physicians receiving Health IT incentive payments under Medicaid are eligible for up to approximately $64,000 over a five year period if they can demonstrate “meaningful use” of EHRs in their practice.

Will nearly double e-Prescribing adoption over MIPPA levels by 2014 and four fold over current levels

Saving of over $22 billion in federal costs will offset $19 billion investment

Savings of over $56 billion for all payors Will help prevent more than 3.5 million

serious medication errors (ADEs)

Visante Report 2009

1-4% reduction in drug spending Pharmacy costs decrease 3-3.5% (Mass eRx Collaborative

2006) 3.3% increase in tier 1 prescribing (Archives Internal Medicine

2008) Generic use increased 4.8% (Sierra/SW Medical 2006) 5.3% reduction drug costs (JMCP 2005) Increased generic use from 65.7-67.6 (HAP/HFMG 2006) 3.7% increased generic prescribing and 10.1% decrease in

cost (WellPoint/Wellinx 2005) 11% decrease drug costs and $4.99 decrease per prescription

(Ann Fam Med 2004) Increased use of mail in service pharmacy 10% (Drug Benefit

Trends 2003) Increased formulary compliance by more than 5% and

increased generic use by 7% (Aetna 2008)

Visante Report 2009

INCREASED ADHERENCE, DISEASE MANAGEMENT AND COORDINATION OF CARE

0.25% reduction in ER and hospital costs

1% increase use of target drugs for chronic disease and

DM management saves 15% in costs (HealthPartners 2007)

Hyperlipidemia treatment compliance increased from 50%-90% of benchmark (Project ImPACT 2000)

Increased use of ACE-inhibitors for DM+HTN (CITL 2003)

PREVENTION OF ADE RELATED HOSPITALIZATION, ER AND PHYSICIAN VISITS

35% decrease preventable ambulatory ADEs with 0.05% decrease hospital, ER and physician costs

30-50% decrease of 8 million ambulatory ADEs (RAND 2005)

9.5% of new prescriptions changed or cancelled due to drug/drug interaction warnings (HAP/HFMG 2006)

Visante Report 2009

Consider starting e-prescribing this year to take best advantage of Medicare incentives as they will decrease starting in 2011 and Medicare reimbursement will decrease in 2012 if you are not e-prescribing.

Evaluate your patient population to see which of the programs you may qualify for

Evaluate your practice setting for decision on what type of product to implement and potential resources for support

Be sure any potential vendors for either e-prescribing stand alone products (Medicare MIPPA e-prescribing program only) or EHR products are current year CCHIT certified.

Carefully evaluate any potential vendor to be sure they meet other restrictions. For ARRA incentives it will be critical to be sure your vendor is prepared for potential further requirements by HHS and ONC for capabilities to meet the “meaningful use” criteria.

Be sure your billing system will be prepared to handle Medicare electronic prescribing specific codes and possible new codes required for ARRA incentives.

Medical Informatics Organizations HIMSS, eHI, AMIA etc

Vendor and vendor user groups Surescripts/RxHub

Medical Societies State or regional medical societies Medical specialty society chapters

IPA or other regional physician groups Hospital or Medical Center State Department of Health or other state agencies Health Plans or Employer groups sponsoring projects Pharmacies and Pharmacist organizations Consultants

1. Electronic Prescribing for the Medical Practice: Everything You Wanted to Know But Were Afraid to Ask, Patricia L. Hale, PhD, MD, FACP, Editor www.himss.org/bookstore and also the e-Prescribing resource center on the HIMSS web site at: http://www.himss.org/ASP/topics_eprescribing.asp

2. E-Prescribing - A Clinicians Guide - e-Health Initiative 2008 http://www.ehealthinitiative.org/assets/Documents/e-Prescribing_Clinicians_Guide_Final.pdf

3. E-Prescribing and health information technology. Davis, Ronald, 2008. American Medical Association. http://www.ama-assn.org/ama/pub/category/18579.html.

4. National Progress Report on E-Prescribing. 2007. SureScripts. http://www.surescripts.com/pdf/National-Progress-Report-on-EPrescribing-1.pdf.

5. For more information on the Medicare incentive program: PQRI Toolkit - http://www.cms.hhs.gov/PQRI/31_PQRIToolKit.asp and for MIPPA- http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3200

6. Evidence on the Costs and Benefits of Health Information Technology. May 2008. Congressional Budget Office, page 17. http://cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf

7. Physicians' Experiences Using Commercial E-Prescribing Systems - Physicians are optimistic about e-prescribing systems but face barriers to their adoption. - by Joy M. Grossman, Anneliese Gerland, Marie C. Reed, and Cheryl Fahlman - Health Affairs April 6, 2008

8. Free e-prescribing readiness assessment online - http://www.getrxconnected.com/

9. E-Prescribing: Why the Fuss? Kenneth G. Adler, MD, MMM FAMILY PRACTICE MANAGEMENT Preprint | www.aafp.org/fpm -

10. Surescripts/RxHub - http://www.surescripts.com/get-connected.aspx?ptype=physician

11. Electronic Prescribing: Building, Deploying and Using E-prescribing to Save Lives and Save Money – Center for Health Transformation 2008

12. HIMSS e-Prescribing Wiki: www.himsseprescribingwiki.pbwiki.com

The HIMSS E-Prescribing Task Force will continue to develop: “tip sheets” for providers on how to incorporate E-

Prescribing solutions into the medical practice HIMSS E-Prescribing interactive Wiki

www.himsseprescribingwiki.pbwiki.com Comments and recommendations on e-Prescribing

issues such as CCHIT certification, definition of “meaningful use” criteria, etc.

HIMSS will leverage Virtual Conference and Exhibition programs to highlight E-Prescribing and provide education updates.

Join us!

“We tried dedicating this computer to deciphering our doctors' handwriting."Cartoon by Dave Harbaugh

pathale@pathalemd.com

Web site with further information and links: www.pathalemd.com

pathale@pathalemd.com

Web site with further information and links: www.pathalemd.com

QUESTIONS?